Brain Abscess and Subdural Empyema in Neonates and Children - Guideline for management of |
Publication: 11/06/2012 -- |
Last review: 09/05/2019 |
Next review: 01/05/2022 |
Clinical Guideline |
CURRENT |
ID: 2964 |
Approved By: Improving Antimicrobial Prescribing Group |
Copyright© Leeds Teaching Hospitals NHS Trust 2019 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Guideline for Management of Brain Abscess and Subdural Empyema in Neonates and Children
Summary Brain Abscess and Subdural Empyema in Neonates and Children |
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Background | ||||||||||||||||||||||||||||||
A brain abscess is a focal, intra-cerebral infection, which usually begins as an area of cerebritis and develops into a collection of pus surrounded by a well-vascularised capsule. A brain abscess evolves through stages of early, late cerebritis followed by encapsulation. Intraventricular rupture of the brain abscess is associated with high mortality. A brain abscess is initiated when microorganisms are introduced into the brain tissue following trauma; contiguous pericranial infection; meningitis or haematogenous dissemination from a distant infective focus. In the largest paediatric series (Tekkok 1992) infections involving middle ear, paranasal sinuses, penetrating trauma and congenital cyanotic heart disease were the most common predisposing factors. Haematogenous spread resulting from sepsis is less common. There are no randomised controlled trials of therapy for children with brain abscess from which to draw recommendations. Available literature is largely retrospective, reviewing predisposing factors, microbiological features, treatment outcomes and prognostic indicators. Data on children is further limited as these series are based mainly on adults with a small number of children; subset data on children are not available in any of them. Hence the text that follows is based on current practice, expert recommendations and the limited literature. Advances in neurosurgical techniques, newer antimicrobials and better imaging technologies have facilitated the diagnosis and management of intracranial pyogenic suppurations over past 20 years; however, it still remains a potentially fatal central nervous system infection. Different factors had been described as influencing the outcome in studies including neurological status at admission, (intraventricular rupture of brain abscess) and multiple abscesses. Imaging severity based on number, location, extent of perilesional oedema and midline shift is also an important prognostic indicator (Demir MK 2007). Infancy is recognised as a risk factor for mortality (Tekkok 1992). Early recognition and management of predisposing conditions is important for improving the overall outcome. Brain abscesses are frequently polymicrobial, the most common etiologic organisms in clinical series have been microaerophilic Streptococci and anaerobic bacteria. Additional organisms such as Staphylococcus aureus and Enterobacteriaceae are also seen depending on the underlying source. Streptococci, Staphylococci and Proteus were the commonest organisms in one paediatric series (Tekkok 1992).
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Investigation | |||||||||||||||||||||||||||||||||||
Recommendation: CT head, ideally with contrast administration, is the imaging modality of choice. Recommendation MRI head may be required in some cases, following discussion with radiology. CT scanning, preferably with contrast administration, provides a rapid means of detecting brain abscesses, the size, the number, and the location. MRI scanning is superior to CT and helps establishing the diagnosis by early recognition of cerebritis in a small number of cases where a CT scan may miss the diagnosis. Only 3/96 cases were detectable only on MRI (Hakan, 2006). An abscess appears as a ring-enhancing, space occupying lesion. Brain abscess development can be divided into 4 stages: 1) Early cerebritis (1-4 days); 2) Late cerebritis (4-10 days); 3) Early capsule formation (11- 14 days); and 4) Late capsule formation (> 14 days). In the earlier phases, a CT scan performed without addition of contrast may show only low-attenuation abnormalities with mass effect. In later phases, a complete peripheral ring may be seen. On CT scans obtained after administration of contrast material, uniform ring enhancement is virtually always present in later phases. In early phases, the capsule will be difficult to visualize via conventional techniques and double contrast CT often is helpful in defining encapsulation of abscess. Metastatic tumours, high-grade gliomas, cerebral infarction, resolving cerebral contusion or haematoma, lymphoma, toxoplasmosis, demyelinating disease and radiation necrosis must be kept in mind as the differential diagnosis for brain abscesses, appearing as ring-enhancing lesions. 113 out of 130 cases (Tekkok 1992) were supratentorial and those related to congenital heart disease had a predilection for left parietal lobe. CT or MRI scan may also reveal an infected source such as a paranasal sinus or an ear infection. Unfortunately, there are no laboratory data that are pathognomonic of brain abscess. WCC may be normal. CRP is elevated in up to 60% of patients. Recommendation: The best way to make a microbiological diagnosis is by culturing of abscess material obtained at the time of surgery, which may be aspiration or excision. Recommendation: Pus collected in a sterile universal container (NOT SWAB) should be sent to Microbiology for urgent microscopy, culture and sensitivity. Recommendation: Blood cultures should be obtained when a brain abscess is suspected (prior to commencing antimicrobial therapy). Haematogenous spread may be the mechanism of CNS infection and a positive blood culture result may help guide therapy and subsequent investigations. Recommendation: Lumbar puncture (LP) is absolutely contraindicated in any child in whom a brain abscess is suspected because of the potential for CNS herniation. Role of imaging in monitoring response to therapy CT scans alone are unreliable in measuring response to treatment since radiological changes lag behind both the reduction in size of the cavity and the clinical response. Complete resolution of the abscess and associated abnormal contrast enhancement may take up to 12–16 weeks, and a small area of residual contrast enhancement may be present for up to 6 months after antibiotic therapy alone or in combination with stereotactic aspiration or surgical drainage via craniotomy. The size of the abscess decreases in 1–4 weeks with antibiotic therapy alone or in combination with stereotactic aspiration, and 95% of abscesses that resolve with antibiotic treatment alone demonstrate a reduction in size within a month. (Brook, 2004)
* Abbreviations: CE = contrast enhancement |
Treatment | ||||||||||||||||||
Non-Antimicrobial Treatment | ||||||||||||||||||
Recommendation: The treatment of brain abscesses should be a team approach, with collaboration between a Microbiologist, neurologist, neuroradiologist and neurosurgeon. Surgical management Stereotactic Aspiration Craniotomy Intraventricular rupture of an abscess, evident due to hydrocephalus and enhancement of ventricular walls, requires surgical debridement, ventricular drainage, and intraventricular and systemic antibiotic treatment. Alterations in the level of consciousness may herald impending herniation and should prompt surgical drainage of the abscess to alleviate mass effect. Neuroendoscopy Lesion Location Cerebellum Brainstem Management of multiple brain abscess Intraventricular rupture of brain abscess |
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Empirical Antimicrobial Treatment | ||||||||||||||||||
Recommendation: Initial antimicrobial choice is empirical and should be tailored to cover the most likely pathogens in individual cases depending upon the location of the abscess and predisposing focus (dental, paranasal sinuses, otogenic etc.), according to Table 2. Recommendation: Wherever possible (e.g. in stable children in whom early surgery/drainage is planned) empirical antimicrobial therapy should be started after surgical drainage, or, if this is not possible, after blood cultures have been taken. Recommendation: Broad spectrum empirical antimicrobial regimens should be tailored to organism isolated from pus or blood cultures i.e. converted to “directed antimicrobial therapy” whenever possible (see Table 3). Antimicrobial therapy
* Use Ceftazidime There have been a number of more recent case reports demonstrating successful non-operative treatment of brain abscess with antibiotics alone. This approach may be appropriate for clinically stable patients who are poor candidates for surgery or for patients with surgically inaccessible lesions. Small lesions (2 cm) located in the better-vascularised cortical areas are more likely to respond to antibiotics alone. Medical treatment alone should not be used when the diagnosis is in doubt or when pathological confirmations are not available. Serial CT or MRI scans are crucial because abscesses may enlarge despite antibiotic treatment. If neurological deterioration occurs as a consequence of mass effect, surgical removal may become necessary. The patient can be switched onto oral therapy when: Evidence Level C
Please contact Microbiology to discuss oral antimicrobial options. |
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Directed Antimicrobial Treatment (when microbiology results are known) | ||||||||||||||||||
Recommendation: Broad spectrum empirical antimicrobial regimens should be tailored to organism isolated from pus or blood cultures i.e. converted to “directed antimicrobial therapy” whenever possible (see Table 3).
**Dose adjusted according to estimated creatinine clearance; need to monitor Vancomycin Treatment of Primary Focus |
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Duration of Treatment | ||||||||||||||||||
Recommendation: Duration of therapy should be determined by clinical progress, CT findings and whether surgical drainage has been undertaken. Recommendation: A minimum of 4 weeks treatment (usually 6-8 weeks) is required if the abscess is treated with antibiotics alone (demonstrate resolution of ring enhancing lesions on CT before stopping antibiotics). Recommendation: Give 3-4 weeks if abscess has been excised and 4-6 weeks if abscess has been aspirated or excised, provided the clinical response is good. The appropriate duration of antimicrobial therapy for brain abscess remains unclear. A 6–8 week course of parenteral antibiotics has traditionally been recommended provided the aetiological organisms are susceptible and that adequate surgical drainage can be established. More recently, shorter durations of antibiotic therapy have been proposed based on correlation between clinical progress and CT findings. |
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Treatment Failure | ||||||||||||||||||
Recommendation: Discussion between neurosurgery and microbiology is recommended. |
Provenance
Record: | 2964 |
Objective: | Aims Objectives |
Clinical condition: | Brain abscess and subdural empyema in neonates and children |
Target patient group: | Children and neonates with brain abscess and subdural empyema |
Target professional group(s): | Secondary Care Doctors Pharmacists |
Adapted from: |
Evidence base
Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
- The rational use of antibiotics in the treatment of brain abscess REPORT BY THE `INFECTION IN NEUROSURGERY’ WORKING PARTY OF THE BRITISH SOCIETY FOR ANTIMICROBIAL CHEMOTHERAPY* British Journal of Neurosurgery 2000; 14(6): 525- 530
- Brook I. Brain abscess in children: microbiology and management. J Child Neurol 1995 Jul; 10(4):283-8.
- Tekkök IH, Erbengi A. Management of brain abscess in children: review of 130 cases over a period of 21 years. Childs Nerv Syst. 1992 Oct; 8(7):411-6.
- Yogev R,Bar-Meir M. Management of brain abscesses in children.Pediatr Infect Dis J. 2004 Feb;23(2):157-9
- Demir MK, Hakan T, Kilicoglu G, Ceran N, Berkman MZ, Erdem I, Göktas P. Bacterial brain abscesses: prognostic value of an imaging severity index. Clin Radiol. 2007 Jun;62(6):564-72.
- Mathisen GE, Johnson JP. Brain Abscess. Clin Infect Dis. 1997; 25: 763-781
- Sheehan et al. Brain abscess in children. Neurosurg Focus.2008 Jun ;24:
Approved By
Improving Antimicrobial Prescribing Group
Document history
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